AHA/ACC Guidelines (2007) – Perioperative Cardiovascular ...



AHA/ACC Guidelines (2007) – Perioperative Cardiovascular Evaluation of the Patient undergoing Non-cardiac Surgery

Take Home Message = if assessment and evaluation not indicated irrespective of perioperative context then just crack on.

3 factors involved in risk stratification:

1. Patient risk factors (high, intermediate and low risk)

2. Functional capacity (>4 METS = low, 170)

- DM (on insulin)

Risk of Perioperative Cardiac Events (AMI, APO, CVA, arrhythmia, death)

0 factors = 0.4%

1 = 1%

2 = 6.6%

3-5 = 11%

MINOR RISK FACTORS

- advanced age

- abnormal ECG

- arrhythmia

- low functional capacity

- previous CVA

- uncontrolled HT

Functional Capacity

1 MET = personal cares

2 METS = walk indoors

3 METS = walk a block on level ground, dusting and washing dishes

4 METS = climb a flight of stairs or walk up hill

5 METS = run a short distance

6 METS = scrubbing floors or lifting heavy objects

7-9 METS = golf, bowling, dancing, doubles tennis, throwing rugby ball

>10 METS = swimming, singles tennis, basketball, skiing

Surgery

HIGH RISK (>5%)

- major emergency surgery

- aortic or major open vascular surgery

INTERMEDIATE RISK (1-5%)

- intraperitoneal and intrathoracic surgery

- carotid endarterectomy

- head and neck surgery

- orthopaedic surgery

- prostate surgery

LOW RISK ( delay surgery 2-4 weeks and keep anti-platelet agents going

- bare metal stent -> delay surgery 4-6 weeks (will be on clopidogrel for this time too)

- drug eluting stents -> delay surgery for 12 months (will be on dual platelet therapy), if patients must undergo therapy keep aspirin going and restart clopidogrel as soon as possible

Perioperative management of patients with prior PCI

- see above time frames (4 weeks, 6 weeks & 12 months)

- try and keep dual anti-platelet therapy going

- if can’t keep aspirin going and reinstitute clopidogrel as soon as possible

- there is no evidence that other agents decrease risk of stent thrombosis

Perioperative management of patients who have received intracoronary brachytherapy

- gamma or beta brachytherapy used to treat recurrent in-stent restenosis

- continue anti-platelet agents if possible

Perioperative management of the patient who requires PCI and surgery soon after

- use same time lines based on when surgery indicated

- 4 weeks -> balloon

- 6 weeks -> bare metal stent

- 12 months -> drug eluting stent

- can put stents in and then deal with restenosis if it takes place

- also CABG + non-cardiac surgery an option

Perioperative Beta-blockers

- aim = to decrease perioperative MI and death

- should start weeks prior to surgery

- use longer acting agents

- aim for a HR turn off their tachyarrhythmia treatment algorithms, place defibrillation paddles far away from device (AP ideal)

Otherwise standard care

POSTOPERATIVE

- monitor clinically for MI

- if develops PCI needs to considered in context of bleeding risk

- manage acutely with early consultation with cardiology

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download